Provider Demographics
NPI:1326088428
Name:JOHNSON, DARRY S (MD)
Entity Type:Individual
Prefix:
First Name:DARRY
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE F-1
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4636
Mailing Address - Country:US
Mailing Address - Phone:602-938-6960
Mailing Address - Fax:602-938-6069
Practice Address - Street 1:5620 W THUNDERBIRD RD
Practice Address - Street 2:SUITE C-1
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4636
Practice Address - Country:US
Practice Address - Phone:602-938-6960
Practice Address - Fax:602-938-6069
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ214002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ168361Medicaid
AZ130014270Medicare PIN
AZ168361Medicaid
AZF58828Medicare UPIN
AZZ13WCFGW06Medicare PIN
AZZWCKJD63Medicare PIN